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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600015
Report Date: 05/02/2022
Date Signed: 05/02/2022 03:59:05 PM

Document Has Been Signed on 05/02/2022 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GRACE HAVEN HOMEFACILITY NUMBER:
198600015
ADMINISTRATOR:ANTONIO SANTOSFACILITY TYPE:
735
ADDRESS:7519 LAURA STREETTELEPHONE:
(562) 928-6833
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY: 4CENSUS: 2DATE:
05/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator Antonio Santos TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Licensee Daisy Lizano and Administrator Antonio Santos. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (2) client records, (2) staff files, and (2) client medications. Currently the facility has (2) clients of which (2) are ambulatory. The facility is vendorized through South Central Regional Center. Facility is a one story family home with three (3) bedrooms. Bedrooms #1 and #2 is for one (1) client each. There is (1) bedrooms for Live in staff. There is (1) bathroom for client use. There is also a living room, a kitchen, central air and heating, a dining area, a den, a shaded area located in the backyard. An attached car garage. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#2 are equipped with a (1) bed each, a dresser, lamp, chair, overhead lightning for each client. Bathroom #1 has a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided to Administrator Antonio Santos.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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